The Shouldice Repair 2016

The advent of tension-free repairs for inguinal hernias, made possible by olefins such as polypropylene, has supplanted pure tissue repairs. This concept was introduced in Marseille, France, in 1944 by Don Acquaviva who used nylon which was available at the time. In this new concept, the defect was left intact and covered with a sagittate prosthesis which became the prototype of today’s precut onlay meshes. It is true that up until the late 1950s pure tissue repairs and Bassini in particular gave poor results which meant, high recurrence rates. The same fate would befall the Shouldice operation. It soon became obvious that these eponymic operations were poorly understood and performed. They needed a delicate knowledge of anatomy. When properly carried out, pure tissue repairs gave equally good results according to several series. Meshes were to facilitate the task by obviating the need for knowledge of anatomy. This expectation did not materialize. Experience revealed also that there are situations when mesh is indicated and a balance is now being established through what has been referred to as “tailored approach.” Mesh if necessary but not necessarily mesh. Meshes have at last revealed a weighty downside, chronic post-herniorrhaphy pain. While its etiology is uncertain, there seems to be a mechanism of pressure, erosion, and invasion into adjacent tissues in a worrisome number of cases. In many instances now, meshes are being removed. Patients are becoming more knowledgeable thanks to the internet and are now asking for surgery without mesh. Let us be ready.